Hospitals in pursuit of excellence

Improving Med Safety for Newborns

Rethinking a registration process kept its meds system in compliance. St. James Hospital and Health Centers, Chicago Heights and Olympia Fields, Ill., used SBAR evaluation to improve medication administration for newborn patients. Situation: Reducing the amount of medications given as "zero orders" in the nursery. Background: During compliance analysis, the nursery had the highest rate of zero order use among all inpatient care units using a barcoded medication administration process. Assessment: Though Illinois requires certain medications to be administered within one hour of birth, zero order use bypasses safety systems. Recommendation: In November 2009 a task force gathered data and developed a newborn pre-registration process, which was implemented in February 2010. When outcomes did not improve after two months, staff reevaluated the process to fit it into their workflow and also changed the process for banding newborns. With the new improved process, zero orders have decreased 40 percent. Contact Theresa Dybala, RNC, assistant patient care manager, at Theresa.Dybala@franciscanalliance.org